In an inpatient environment, a patient's fluid balance must be carefully monitored by care-providers. A multitude of health problems, ranging from mild to severe, can arise from either extracellular fluid depletion or extracellular fluid overload. Fluid depletion can result in a variety of problems, such as dizziness, anxiety, confusion, decreased consciousness, weight loss, dry mucous membranes, thready pulse, peripheral vasoconstriction, decreased systolic pressure, increased respiration rate, and a host of other problems. Fluid overload can result in many of the same problems, as well as dependent oedema, pulmonary oedema, abdominal ascites, hepatomegaly, weight gain, raised jugular venous pressure, third heart sound, dyspnoea, ortopnoea, and other problems. Even severe medical problems such as heart attacks or strokes can result from improper fluid balance.
One way of monitoring a patient's fluid balance is to monitor a patient's intake and output (I/O). Currently, I/O documentation is performed manually. For each intake and output event, a healthcare professional must record the volume as well as the type of event. Examples of intake and output events include administration of intravenous fluids, laboratory sample collections, urination, eating, and drinking. Even in computerized healthcare environments, healthcare professionals manually input the I/O data into an I/O balance portion of a patient's electronic medical record. This manual documentation process can lead to errors in the patient's I/O from omitted I/O events or inaccurate data entry.
A particular problem caused by the current manual I/O documentation process results from various departments conducting procedures on a patient that impact the patient's I/O, but failing to document the procedures in the patient's I/O balance. Particular procedures such as the collection of blood samples and urine samples may involve relatively small quantities individually, but can result in large changes in a patient's I/O when added together and considered as a whole. These laboratory procedures, because of their small volumes, are frequently not documented in the patient's I/O. Additionally, administration of radiology contrast media by radiology departments is also often not documented in the patient's I/O. Contrast media quantities administered can often be as high as 500 mL, which could have a dramatic impact on the patient's overall fluid balance.
A process of automatically documenting a patient's I/O and including traditionally undocumented I/O events, such as laboratory procedures and radiological procedures, which would not rely on manual entry, is needed.